Background: Medical education throughout the world poses the incoming student with many challenging situations and demands. This forms an ideal environment for the student to be under stress as he/she adapts to these stress-inducing conditions. Factors both psychosocial and otherwise, vary widely between institutions of learning, the demographic studied, the external influences of the environment/country, and the stage of learning of the student, among other factors. Aims and Objective: To assess the prevalence of stress among first-year medical undergraduate students and to segregate the potential stressors derived from the study. Materials and Methods: This is a cross-sectional study involving the first-year medical students. Prevalence of stress was assessed using Cohen's Perceived Stress Scale (PSS-10), which is an internationally validated 10-item questionnaire. The effect of potential stressors was assessed using a 33-item questionnaire. The stressors were categorized as academic, psychosocial, and health-related. Result: Of the 147 respondents, the mean PSS score was 21.09 (SD: 4.7). Of them, 105 students (71.4%) reported moderate stress, 16 students (10.9%) had high stress, and 26 students (17.7%) reported low/no stress. The top five stressors were all academic or psychosocial stressors. Conclusion: The vast majority of students perceived moderate stress and analysis highlighted a greater association with academic factors compounded by psychosocial ones. Preventive mental health measures on the basis of this and further studies into the occurrences of stress in the early academic years of a medical professional, followed by effective management tools and programs could go a long way in counteracting the harmful long-term effects of stress on their careers, producing happier and more productive and efficient medical professionals.

INTRODUCTION: Esophageal stenosis after radiotherapy occurs in up to 15% of patients within 3 months of treatment. Endoscopic dilation remains the standard of care for cervical esophageal stenosis with refractory cases requiring stenting. Proximal stenosis pose a challenge as standard esophageal stents can cause cervicalgia and globus sensation due to their size and expansive force making the a biliary SEMS a better solution. CASE DESCRIPTION/METHODS: Patient is a 72 year-old Vietnamese male with pertinent past medical history of stage IV laryngeal cancer status post total laryngectomy, radiotherapy, and tracheostomy presenting with recurrent dysphagia. Patient had previously undergone four endoscopic dilations within the previous month for the same complaint. Upper endoscopy at time of admission revealed a recurrent benign stricture at the level of the upper esophageal sphincter. Given previous failed dilations, severity of stricture, and patient’s refusal for surgical correction or a gastrostomy tube, a biliary SEMS was placed with palliative intent. A fully covered biliary SEMS measuring 10 mm × 60 mm was deployed at the level of the stricture resulting in symptom resolution for 5 months. On recurrence of dysphagia, evaluation revealed distal migration of the SEMS. Retrieval was unsuccessful and the existing SEMS was overlapped with another 10 mm × 60 mm biliary SEMS which resulted in a symptom-free interval of 11 months. Both SEMS were retrieved and exchanged for a fully covered esophageal SEMS (18 mm). Patient had persistent symptoms and endoscopy revealed proximal migration of the esophageal SEMS. The esophageal SEMS was retrieved and a biliary SEMS (10 mm) was again deployed at the level of the stricture which resulted in resolution of symptoms. Patient has since had the stent exchanged every 3-4 months due to stent migration. DISCUSSION: Recurrent proximal esophageal stenosis pose a challenge for endoscopists due to their challenging anatomy. Standard esophageal stents currently available in the market start at a diameter of 12 mm making it less ideal for proximal esophageal strictures that cannot tolerate the expansive force of the larger stents. We have demonstrated the success of using a smaller-diameter biliary stent for the relief of dysphagia along with longer symptom-free intervals when compared to dilation and standard esophageal stents. This case demonstrates the need for further research and development of specialized esophageal stents for the treatment of recurrent proximal esophageal stenosis.

INTRODUCTION: Transaminitis is not an uncommon consult for a gastroenterologist. The presence of profound transaminitis in the setting of septic shock often skews our etiology towards shock liver and other more common causes of acute liver injury in the absence of previous known liver pathology. HLH is a rare cause of acute liver injury but lack of prompt diagnosis and treatment can make the difference in outcome. CASE DESCRIPTION/METHODS: Patient is a 27 year old male with no known past medical history who presented with a two week history of fever in which he took acetaminophen every four hours. Reported history of alcohol consumption of 12 beers per day for three years. History remarkable for a camping trip to Oklahoma two to three weeks prior to admission. No history of NSAID or herbal use. No personal or family history of liver disease. Patient admitted to the ICU and treated for septic shock and subsequently started on N-acetylcysteine in the setting of acetaminophen use and acute liver injury. Patient had worsening renal function requiring initiation of dialysis, acute respiratory failure requiring intubation during evaluation. Gastroenterology consulted on hospital day two in which complete hepatic evaluation was initiated with remarkable findings of markedly elevated ferritin and positive Ebstein-Barr virus (EBV). Suspicion of Hemophagocytic lymphohistiocytosis (HLH) noted per Gastroenterology given high ferritin and diagnostic criteria being met. This prompted recommendations for evaluation by Hematology in which bone marrow biopsy confirmed HLH and prompt treatment with Rituxan, Dexamethasone and subsequent clinical improvement. DISCUSSION: EBV-HLH is an uncommon entity that is encountered on a daily basis. However, the mortality associated with the disease process is high if timely intervention is not implemented. A constellation of clinical features and laboratory results comprise clinical diagnosis of HLH combined with multi-speciality contribution to formulate the diagnosis. Transaminitis, elevated ferritin, cytopeniae should not skew a clinician's thought process towards shock liver altogether and EBV-HLH should be high on the differential early in the clinical course. Gastroenterology will be involved frequently in management due to transaminits and gastrointestinal bleeding manifesting frequently. Early treatment of EBV-HLH with immunosuppressants has shown to reduce mortality by 40% mandating more awareness about the disease in Gastroenterology and be a guiding light in the management.